A Meta-Analysis of Mitral Surgery in Patients Undergoing Surgery for Anomalous Left Coronary Artery: When to Perform Repair?

The present study is the first meta-analysis comparing long-term outcomes in patients undergoing correction for anomalous left coronary artery (ALCAPA) regarding concomitant mitral valve surgery. A systematic literature review was conducted to identify all relevant studies with comparative data on mitral valve surgery performed during surgery for ALCAPA correction. Predefined primary end points included mortality and mitral valve (re)operation. Echocardiographic outcomes were assessed when available (including severity of mitral regurgitation). Fifty-three relevant retrospective studies with comparative data for ALCAPA patients with concomitant mitral valve surgery were identified from the existing literature. The study population included 3,851 patients, of whom 55% were girls. The mean age at surgery was 6 months [0-99 months]. The mean follow-up after surgery was 22.7 years [6.3-37.2]. Among patients with available echocardiographic data at the time of ALCAPA correction, 283 had no mitral regurgitation (13%), 642 had mild mitral regurgitation (30%), 756 had moderate mitral regurgitation (36%), and 437 had severe mitral regurgitation (21%). A subgroup of patients who underwent mitral valve surgery (yMVS; n = 753; 19.5% of the total population) was identified. A total of 228 patients died during follow-up (5.9%), with no differences among patients who underwent vs those who did not undergo mitral valve concomitant surgery at baseline (p = ns). Among the 1,536 patients with available follow-up echocardiographic data, 519 had no mitral regurgitation (34%), 663 had mild mitral regurgitation (43%), 268 had moderate mitral regurgitation (17%), and 86 had severe mitral regurgitation (6%). Overall, during follow-up, 91 patients underwent mitral valve surgery (first MVS for 20 pts and reintervention for 71 pts, representing a 10% reintervention rate). In regression analysis, we found no association between the mean age at first surgery and the need for reoperation (p = 0.458). Mitral valve surgery is performed in about 20% of patients undergoing ALCAPA correction. Indications for MVS vary among centers, although the severity of MV regurgitation was the most common criterion (more than 50% of the yMVS group). Of yMVS patients, approximately 10% underwent a second MVS during follow-up, regardless of age at first surgery. Overall, long-term mortality in these patients is over 5%, with no evident impact related to concomitant MV surgery.